Neuro Incoordination Intake

Ms. Evelyn Parker is a 61-year-old right-hand dominant female who was seen at the Regional Medical Center clinic on 2025-06-10 accompanied by no one.

REASON FOR REFERRAL:

Bilateral knee pain and poorly controlled blood sugar levels.

HISTORY OF PRESENT ILLNESS:

Ms. Parker reports bilateral knee pain that started approximately one month ago. She described it as a deep, aching sensation that alternates between knees, with one knee hurting at a time. The pain can become severe enough to impair ambulation. She attributes the onset of the knee pain to prolonged standing on one occasion. She denies any fluid buildup or swelling in the knees and has not used any ointments for the pain. She also reports bilateral shoulder discomfort, which she associates with weather changes, as well as occasional back and neck pain, though these do not radiate to other areas.

She experiences occasional dizziness, particularly when bending over or engaging in certain activities, but denies any dizziness otherwise. She denies any recent confusional episodes or seizures, with her last seizure occurring several years ago. She continues to take zonisamide for seizure prevention. She reports occasional restless legs but notes that the frequency has decreased compared to before. She denies current symptoms of attention deficit disorder but mentions occasional memory lapses, such as mixing up days, which she associates with high blood sugar levels.

Her blood sugar levels can reach as high as 400 mg/dL at night, and she administers insulin to manage these episodes. She denies any recent issues with her breathing or COPD symptoms. She has a history of a transient ischemic attack and reports occasional weakness, which she feels affects both sides equally. She denies any current use of tamoxifen for breast cancer, having discontinued it in 2024. She continues to experience mood-related symptoms and takes brexpiprazole for this purpose. She denies any recent use of escitalopram for depression. She reports occasional headaches and uses over-the-counter medications for relief.

PAST MEDICAL HISTORY:

Poorly controlled diabetes mellitus with blood sugar levels occasionally exceeding 400 mg/dL.  
Hypertension.  
History of transient ischemic attack.  
History of breast cancer, previously on tamoxifen, discontinued in 2024.  
History of seizures, with the last episode occurring several years ago.  
Restless leg syndrome, which has decreased in frequency.  
Mood-related symptoms, currently managed with brexpiprazole.  

CURRENT MEDICATIONS:

Zonisamide 200 mg nightly for seizure prevention.  
Brexpiprazole 1 mg daily for mood stabilization.  
Gabapentin 100 mg as needed for restless legs (typically two capsules a few days per week).  
Memantine for memory support.  
Over-the-counter medications for occasional headaches.  

ALLERGY:

No known allergies reported.

FAMILY HISTORY:

Ms. Parker reports a family history of significant emotional distress following the tragic loss of her granddaughter, who was a college student with aspirations and a basketball scholarship. No other specific familial medical conditions or hereditary diseases were discussed.

SOCIAL HISTORY:

Ms. Parker denies the use of Goody Powders. She did not provide additional details regarding her home environment, occupational history, or social activities during this encounter.

EXAMINATION:

On examination today, she was alert and oriented x3. Her attention is normal. Immediate recall was 3/3, and delayed recall was 3/3. Language is within normal limits, including comprehension and fluency.

CRANIAL NERVE EXAMINATION:

Pupils are equal and reactive to light bilaterally. Funduscopic examination showed normal disk bilaterally. Visual fields and extraocular movements are full. Normal facial sensation and strength. Palate is symmetrical, and tongue is midline.

MOTOR EXAMINATION:

Tone and bulk within normal limits. Power is 5/5 throughout. Plantar responses downgoing bilaterally. Reflexes are symmetrical.

SENSORY EXAM:

Normal for light touch, pinprick, and temperature. No new sensory deficits reported.

COORDINATION:

No changes in coordination reported.

GAIT:

No changes in gait stability or posture reported.

INVESTIGATIONS:

No new test results or imaging studies were conducted or reviewed during this phone encounter.

ASSESSMENT AND PLAN:

Ms. Parker is a 61-year-old right-hand dominant female with a history of bilateral knee pain, poorly controlled diabetes mellitus, occasional dizziness, and mood-related symptoms. Her neurological status remains stable with no recent seizures or confusional episodes. She continues to experience occasional restless legs and occasional headaches. Her blood pressure remains elevated, and she has discontinued atenolol. She denies any current breathing problems or COPD symptoms.

Her clinical presentation and physical examination are suggestive of chronic pain syndrome, poorly controlled diabetes, and mood-related symptoms.

We will continue her current regimen of zonisamide for seizure prevention, memantine for memory support, and brexpiprazole for mood stabilization. She is advised to resume atenolol for blood pressure management, as her blood pressure readings have been elevated. She is instructed to monitor her blood pressure twice daily, in the morning and evening, for one week and report the values. Hydrocodone has been prescribed for pain management, and she is encouraged to use a knee brace to alleviate knee discomfort. Gabapentin will continue to be used as needed for restless legs. Montelukast has been re-prescribed to manage her COPD symptoms, and she is advised to take aspirin daily to reduce the risk of further vascular events. Additionally, her prescription for Plavix (clopidogrel) has been renewed to prevent thrombotic events. She is instructed to use over-the-counter medications for occasional headaches and to continue her Emgality injections for migraine prevention. She is also advised to ensure adherence to her bone density medication, alendronate, and to follow up with her pharmacy regarding any refills.

She is encouraged to contact her pharmacy to confirm the dosage of brexpiprazole and ensure proper refills. She is also advised to follow up with her primary care physician or endocrinologist to address her elevated blood sugar levels, which have been reaching as high as 400 mg/dL at night. A referral to a dietitian may be considered to assist with dietary modifications for better glycemic control. Additionally, she is advised to follow up with the Women's Center regarding her bone density test results.

She was counseled on the importance of maintaining consistent blood sugar levels and adhering to her insulin regimen. She was educated on the risks associated with elevated blood pressure and the importance of regular monitoring. She was also advised on the benefits of using a knee brace and the importance of weight management to reduce joint strain. The patient was reminded to take her medications as prescribed and to set reminders to avoid missing doses, particularly aspirin and her bone density medication. She was also provided with information on the potential benefits of physical therapy for her knee and shoulder pain.

She is scheduled for a follow-up appointment on July 5, 2025, to review her blood pressure readings, assess her response to the adjusted treatment plan, and address any ongoing concerns. She is instructed to report any worsening of symptoms, new neurological changes, or significant side effects from her medications prior to the follow-up visit.

Thank you for the referral.

Dr. S Patel  
Regional Medical Center